6 Reports
Inspection Report — Dec 15, 2025
Follow-Up
Date: Dec 15, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Complaint Details
The inspection included a complaint investigation related to staff training, tuberculosis testing, and background checks under complaint number 184876.
Findings
The follow-up inspection found no deficiencies and confirmed that previously cited deficiencies related to training, certification, and tuberculosis testing were corrected.
Deficiencies (5)
WAC 388-78A-2474 Training and home care aide certification requirements. The facility failed to ensure staff completed required first aid training, placing residents at risk. This deficiency was previously cited and remained uncorrected at the time of earlier inspections.
WAC 388-78A-2480 Tuberculosis Testing Required. The facility failed to ensure staff were screened for tuberculosis within three days of hire, placing residents at risk of exposure to infectious disease. This deficiency was previously cited and remained uncorrected at the time of earlier inspections.
WAC 388-78A-2474 Training and home care aide certification requirements. The facility failed to ensure staff completed 70-hour basic training and first aid training within required timeframes, placing residents at risk of compromised care and safety.
WAC 388-78A-2480 Tuberculosis Testing Required. The facility failed to ensure two staff members were screened for tuberculosis within three days of hire, placing residents at risk of exposure to infectious respiratory disease.
WAC 388-78A-2466 Background checks. The facility failed to ensure two staff had valid Washington State background checks completed every two years, placing residents at risk of being cared for by staff with potentially disqualifying backgrounds.
Report Facts
Number of residents: 62
Sample size: 9
Staff with missing training: 3
Staff with delayed TB testing: 4
Staff with missing background checks: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Operations Specialist | Confirmed missing first aid training and delayed TB testing for staff |
| Staff G | Business Office Manager | Confirmed missing training documentation and background checks |
| Staff H | Health and Wellness Director | Explained delay in TB test reading for Staff D |
Inspection Report — Nov 17, 2025
Life Safety
Date: Nov 17, 2025
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility.
Findings
The inspection identified multiple fire and electrical safety violations including combustible storage in prohibited areas, missing light fixture covers, improper wiring, blocked fire doors, and missing documentation for sprinkler and fire alarm system testing. The facility was disapproved due to these unresolved issues.
Deficiencies (8)
IFC 315.2.3 (2021) - There was combustible storage within the elevator equipment room. Combustible material is prohibited in such equipment rooms.
IFC 315.3.4 (2015, 2018) - There was combustible storage under the stairs on the 1st floor stairwell near 161. Storage in such concealed spaces must be protected or prohibited.
IFC 603.1.1 (2021) - The light cover was missing from the light fixture in the stairwell near 253, exposing electrical wiring. Electrical equipment must be properly maintained and protected.
IFC 603.2.2 (2021) - There was a spliced wire not in a junction box for the overhead light in the janitor closet near 207. Open wiring splices are prohibited and must be enclosed.
IFC 603.6 (2021) - There was an extension cord utilized as permanent wiring in the kitchen. Extension cords must not substitute permanent wiring.
IFC 705.2 (2021) - Resident room 316 fire door was blocked open using a rock, preventing it from closing and latching. Fire doors must not be blocked or obstructed.
IFC 903.5 (2021) - Facility is unable to provide documentation for the annual sprinkler system inspection and the 3 year dry system full flow trip test. Sprinkler systems must be tested and maintained with documentation.
IFC 907.8 (2021) - Facility is unable to provide documentation for the annual fire alarm system testing. Records of inspection, testing, and maintenance must be maintained.
Inspection Report — Oct 28, 2025
Enforcement
Date: Oct 28, 2025
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to impose civil fines based on uncorrected deficiencies related to staff training and tuberculosis screening at the assisted living facility.
Findings
The facility was cited for uncorrected deficiencies including failure to ensure one staff member completed First Aid training and failure to ensure two staff members were screened for tuberculosis within three days of hire. These violations placed all residents at risk and resulted in civil fines.
Deficiencies (2)
WAC 388-78A-2474 (2)(b)(d) Training and home care aide certification requirements. The licensee failed to ensure one staff member completed First Aid training, placing all 62 residents at risk of harm.
WAC 388-78A-2480 (1) Tuberculosis—Testing—Required. The licensee failed to ensure two staff members were screened for tuberculosis within three days of hire, placing all residents at risk of exposure to an infectious respiratory disease.
Report Facts
Civil fine amount: 400
Residents at risk: 62
Inspection Report — Jul 7, 2025
Follow-Up
Date: Jul 7, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to resident records and medication administration.
Complaint Details
The complaint investigation (Compliance Determination #55814) was based on allegations that staff were not responding to a named resident's requests for care. The investigation found failed provider practice with missing medication administration documentation for four residents, resulting in a citation for WAC 388-78A-2410.
Findings
The follow-up inspection on 07/07/2025 found no deficiencies; previously cited issues with medication administration records were corrected. The prior complaint investigation found failed provider practice related to incomplete medication administration documentation for four residents.
Deficiencies (1)
WAC 388-78A-2410 Content of resident records. The assisted living facility must organize and maintain resident records in a format that is useful and functional to enable effective care and services. Active resident records must include medical and nursing services provided, including medication assistance and administration details.
Report Facts
Total residents: 64
Resident sample size: 4
Residents with undocumented medication administration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Pederson-Tuley | Nursing Consultant Institutional | Department staff who conducted the follow-up inspection |
| Kimberley Ripley | Field Manager | Investigator who conducted the complaint investigation and signed the statement of deficiencies |
Inspection Report — Nov 29, 2023
Life Safety
Date: Nov 29, 2023
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire protection inspection at the facility on 11/29/2023.
Findings
All violations noted during previous related inspections have been corrected. The facility was approved following this inspection.
Inspection Report — Nov 14, 2022
Life Safety
Date: Nov 14, 2022
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility.
Findings
The inspection identified multiple fire safety violations including improper power supply connections, missing documentation for hood cleaning and suppression system servicing, fire extinguisher maintenance issues, fire alarm system troubles, missing smoke alarms, non-illuminated exit signs, lack of emergency generator servicing documentation, and incomplete fire drill records. The facility was disapproved due to these deficiencies.
Deficiencies (8)
IFC 604.4.2 2018 - Relocatable power taps shall be directly connected to a permanently installed receptacle. There is a power strip plugged into another power strip in the Dining Services Director's office.
IFC 607.3.3 2018 - Hoods, grease-removal devices, fans, ducts and other appurtenances shall be cleaned at required intervals. Facility is unable to provide documentation for the semi-annual hood cleaning.
IFC 904.12.5.2 2018 - Automatic fire-extinguishing systems shall be serviced at least every six months and after activation. Facility is unable to provide documentation for the semi-annual kitchen suppression system servicing.
IFC 906.2 2015 2018 - Portable fire extinguishers shall be selected, installed and maintained per NFPA 10. The fire extinguisher in room 357 has a broken tamper seal. The fire extinguisher in the storage room near 310 has not been serviced in the last 12 months. The fire extinguisher in the mechanical room near 105 has not been serviced in the last 12 months.
IFC 907.8 2018 - Fire alarm and detection systems shall be maintained with records of inspection, testing and maintenance. The fire alarm system is in trouble status. Two single station smoke alarms are missing in the 1st floor guest room.
IFC 1013.5 2018 - Electrically powered, self-luminous and photoluminescent exit signs shall be listed, labeled and illuminated at all times. The internally illuminated exit signs in the corridor near room 153 did not illuminate in normal operation.
IFC 1203.4 2018 - Emergency and standby power systems shall be maintained to supply service within the specified time. Facility is unable to provide documentation for the annual servicing of the emergency generator.
Fire Drills - At least twelve planned and unannounced fire drills shall be held annually with records maintained. Facility cannot provide documentation for the completion of twelve planned and unannounced fire drills in the previous 12 months. Missing drills include 1st Shift Quarters 1 and 4, 2nd Shift Quarters 3 and 4, and 3rd Shift Quarter 1.
Report Facts
Missing fire drills: 5
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